Eating Disorders on Campus: A Procedure for Community Intervention

Concern for students with eating disorders and concern for the environment served as the catalyst for the development of a procedure for responding to eating disorders. The procedure, which relies heavily on residence hall staff, is presented here, with emphasis on training, prevention, and issues in implementation.     

Assessment and Diagnosis of Eating Disorders: A Guide for Professional Counselors

Despite the prevalence of and risk associated with disordered eating, there are few guidelines for counselors on how to conduct an eating disorder assessment. Given the importance of the clinical interview, the purpose of this article is to provide recommendations for the assessment and diagnosis of eating disorders that (a) specifically focus on assessment in the context of a clinical interview and (b) can be used by counselors whether or not they specialize in eating disorder treatment.     

A Description of the Continuum of Eating Disorders: Implications for Intervention and Research

Many authors have proposed the notion of an eating disorder continuum to aid in the understanding of similarities and differences among various types of eating disturbances and disorders. The purpose of this article is to present an eating disorders continuum and to describe groups on the continuum by highlighting differences among the groups on behavioral, cognitive-attitudinal, and self-esteem issues. The relationship of the continuum to the developmental course of eating disorders is discussed. Prevention, early intervention, and treatment programs for various groups on the continuum are presented. Recommendations for future research on the continuum of eating disorders are provided.     

Nutritional Intervention in Young Women with Eating Disorders: A Brief Report

Eating disorders in young women are often associated with a number of comorbid conditions, including mood disorders and cognitive problems. Although group therapy is often used as part of overall treatment for eating disorders in many types of settings, specific nutritional interventions used in such settings have rarely been evaluated. In this study, I evaluated the effects of a nutritional intervention used by 78 girls, aged 12–18 years, at a private school. My results showed that nutritional knowledge increased following intervention, but attitudes toward eating healthy did not change.     

Enhanced Cognitive Behavior Therapy: A Single Treatment for All Eating Disorders

Eating disorders are serious mental illnesses affecting a significant proportion of women and a smaller number of men. Approximately half of those with an eating disorder (ED) will not meet the criteria for anorexia or bulimia nervosa, and will be diagnosed with an eating disorder not otherwise specified (EDNOS). Until recently, there were no recommended treatments for EDNOS. This article provides an overview of enhanced cognitive behavior therapy, a validated treatment for all forms of EDs.     

A Mixed Model to Disentangle Variance and Serial Autocorrelation in Affective Instability Using Ecological Momentary Assessment Data

Affective instability, the tendency to experience emotions that fluctuate frequently and intensively over time, is a core feature of several mental disorders including borderline personality disorder. Currently, affect is often measured with Ecological Momentary Assessment protocols, which yield the possibility to quantify the instability of affect over time. A number of linear mixed models are proposed to examine (diagnostic) group differences in affective instability. The models contribute to the existing literature by estimating simultaneously both the variance and serial dependency component of affective instability when observations are unequally spaced in time with the serial autocorrelation (or emotional inertia) declining as a function of the time interval between observations. In addition, the models can eliminate systematic trends, take between subject differences into account and test for (diagnostic) group differences in serial autocorrelation, short-term as well as long-term affective variability. The usefulness of the models is illustrated in a study on diagnostic group differences in affective instability in the domain of eating disorders. Limitations of the model are that they pertain to group (and not individual) differences and do not focus explicitly on circadian rhythms or cycles in affect.     

The Effects of Appearance-Based Comments and Non-Appearance-Based Evaluations on Body Dissatisfaction and Disordered Eating Urges: An Ecological Momentary Assessment Study

The current study used ecological momentary assessment (EMA) to investigate whether appearance-based comments, social and performance-based evaluations affected levels of body dissatisfaction (BD) and urges to engage in disordered eating behaviors (DE) throughout daily life. A total of 620 participants completed a baseline questionnaire assessing sociodemographic variables. Participants then downloaded a mobile app which alerted them to complete short surveys assessing their levels of BD, DE urges, and experiences of receiving comments and evaluations six times per day for 7 days. Negative appearance-based comments predicted greater levels of state BD, while positive appearance comments predicted lower levels of state BD. Negative social and performance-based evaluations predicted an increase in state BD, while positive evaluations predicted a decrease in this outcome variable. No significant predictor was found for the DE urge outcomes. The present findings suggest that receiving negative and positive feedback in various domains of one’s life may predict opposite outcomes for body image. However, these effects do not necessarily associate with urges to engage in DE in a nonclinical population.     

Outcomes of a Day Treatment Program for Eating Disorders Using Clinical and Statistical Significance

The present study was designed to evaluate the outcomes of a day treatment program for 55 eating disordered (ED) patients using clinical and statistical significance testing. Results indicated a statistically significant reduction on all eating disordered outcomes. With respect to clinical significance testing, analysis of these data indicated that the majority of the individuals in the day treatment program made clinically significant and reliable change by the termination of treatment on all eating disorder measures. However, considerably less patients improved to such a point that they were asymptomatic. The importance of combining clinical significance testing with traditional significance testing is discussed.     

Stress-Induced Binge Eating: A Behavior Analytic Approach to Assessment and Intervention

Responses to acute or chronic stress may include behaviors, such as alcohol consumption, cigarette smoking, and altered eating patterns. In connection with the stress-eating relation, some researchers have suggested that certain stressors (e.g., psychological or emotional) may influence the direction (i.e., increase or decrease) of a person’s eating response. In a recent study, Connors and Morse (Int J Eat Disord 13:1–11, 2006) indicated that the physical and psychological stress associated with sexual trauma could result in an increase in food intake and nonstandard eating patterns. In consequence, this study describes a multifaceted intervention for a 24-year-old woman who experienced chronic stress and received a diagnosis of Binge Eating Disorder (American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders. DSM-IV. Washington, DC: APA) following a series of unwanted sexual experiences. The behavior analytic intervention emphasized self-control, self-regulation, and physical activity. The treatment package resulted in a 19% reduction in the participant’s body weight, a 96% reduction in binge eating, and long-term adherence to an exercise routine.     

Latent Variable Mixture Modeling of Ecological Momentary Assessment Data: Implications for Screening and Adolescent Mood Profiles

Ecological momentary assessment (EMA) studies typically rely on arbitrary decision rules for identifying and excluding invalid responses from the data. In addition, most studies treat independent variables as separate from each other even if their combinations might have importance above the independent contribution of each. Our study aimed to conduct an exploratory latent profile analysis of EMA data to demonstrate an empirical method of identifying invalid responses, and to provide a preliminary investigation of mood profiles. We recruited 20 adolescents between the ages of 13–18 to complete 4 surveys about their internal states each day for 20 days. Participants provided responses on study smartphones using an Android app developed by the study team. Our profile analysis revealed 9 independent profiles. We determined that 3 of these profiles consisted of invalid responses because the integers provided by the participant were nearly invariant. The invalid responses comprised 24.9% of the sample. We also identified 6 valid profiles that were labeled: fatigued (8.7%), good mood/energetic (19.9%), angry/depressed (2.3%), good mood (37.1%), angry (5.7%), and depressed (1.4%). One important implication of the current study is that researchers and clinicians should screen electronic diary data, especially for invariant responding. In addition, it is important for clinicians to note that more than one internal state may drive the mood of an adolescent patient.     

Conceptualizing and Estimating Process Speed in Studies Employing Ecological Momentary Assessment Designs: A Multilevel Variance Decomposition Approach

Researchers have been making use of ecological momentary assessment (EMA) and other study designs that sample feelings and behaviors in real time and in naturalistic settings to study temporal dynamics and contextual factors of a wide variety of psychological, physiological, and behavioral processes. As EMA designs become more widespread, questions are arising about the frequency of data sampling, with direct implications for participants' burden and researchers' ability to capture and study dynamic processes. Traditionally, spectral analytic techniques are used for time series data to identify process speed. However, the nature of EMA data, often collected with fewer than 100 measurements per person, sampled at randomly spaced intervals, and replete with planned and unplanned missingness, precludes application of traditional spectral analytic techniques. Building on principles of variance partitioning used in the generalizability theory of measurement and spectral analysis, we illustrate the utility of multilevel variance decompositions for isolating process speed in EMA-type data. Simulation and empirical data from a smoking-cessation study are used to demonstrate the method and to evaluate the process speed of smoking urges and quitting self-efficacy. Results of the multilevel variance decomposition approach can inform process-oriented theory and future EMA study designs.     

Conceptualizing and Estimating Process Speed in Studies Employing Ecological Momentary Assessment Designs: A Multilevel Variance Decomposition Approach

Researchers have been making use of ecological momentary assessment (EMA) and other study designs that sample feelings and behaviors in real time and in naturalistic settings to study temporal dynamics and contextual factors of a wide variety of psychological, physiological, and behavioral processes. As EMA designs become more widespread, questions are arising about the frequency of data sampling, with direct implications for participants' burden and researchers' ability to capture and study dynamic processes. Traditionally, spectral analytic techniques are used for time series data to identify process speed. However, the nature of EMA data, often collected with fewer than 100 measurements per person, sampled at randomly spaced intervals, and replete with planned and unplanned missingness, precludes application of traditional spectral analytic techniques. Building on principles of variance partitioning used in the generalizability theory of measurement and spectral analysis, we illustrate the utility of multilevel variance decompositions for isolating process speed in EMA-type data. Simulation and empirical data from a smoking-cessation study are used to demonstrate the method and to evaluate the process speed of smoking urges and quitting self-efficacy. Results of the multilevel variance decomposition approach can inform process-oriented theory and future EMA study designs.     

Targeting Co-Sleeping in Children With Anxiety Disorders Using a Modified Bedtime Pass Intervention: A Case Series Using a Changing Criterion Design

Children with anxiety disorders experience high rates of sleep-related problems, with co-sleeping and resistance to sleeping independently being among the more frequent problems reported. Although extinction-based behavioral sleep interventions have repeatedly been shown to be highly effective for treating bedtime resistance, the primary obstacle to their implementation is parent discomfort with these procedures. The bedtime pass intervention was developed to minimize extinction bursts when implementing extinction procedures for childhood sleep problems. Several studies have found this intervention to be effective for treating bedtime resistance behaviors, but not co-sleeping specifically, in nonclinical samples of children. The current paper describes the use of a modified bedtime pass procedure to target problematic co-sleeping and related bedtime resistance behaviors in two children with anxiety disorders who presented for treatment at an outpatient pediatric anxiety specialty clinic. A changing criterion, single subject methodology was used to evaluate the effectiveness of this procedure. Data indicate that both children were able to transition from co-sleeping with parents every night, to sleeping independently, with relatively limited need for contact with parents at night during the intervention. These findings extend the data for the bedtime pass procedure to both co-sleeping and children with anxiety disorders. Clinical implications of these findings are discussed given the limited guidance for treating comorbid sleep problems in anxious children. Strengths and limitations of the data being drawn from a clinical treatment setting are also discussed.     

Assessment as Intervention: A Pilot Study of Short-Term Dyadic Treatment

Assessment, as an intervention, is a hallmark of infant mental health that has not been evaluated for treatment effectiveness. A comprehensive assessment framework was standardized as a short-term intervention model and evaluated for treatment effects based on dynamic systems theory of change. The transdisciplinary interaction-based assessment model embeds nondidactic developmental guidance interpretations in the context of eliciting child functional capacities while engaging the caregiver in direct co-observation and reflection to challenge inflexibility in parents’ representations. The findings of this pilot project, with a community sample of Spanish- and English-speaking families, suggest this assessment as intervention model has the potential to promote an active process of change in parents’ representations toward a “disorderly,” or unstable state, possibly both in perceptions of self as caregiver and in representations of the child. Clinically, this disorderly state would be seen as an opportunity that could perpetuate the change process, recognizing disorderliness of representation as an opening, as emerging permeability of representations. Results indicate that this caregiver-clinician collaborative process is associated with caregiver reports of decreased distress, increased empathy for child’s difficulties, and changes in caregiver representations. A subset of families, caregivers who hold immutable views of their children, are less responsive to the developmental guidance approach and may require different or more long-term treatment.     

A Cognitive-Behavioral Mindfulness Group Therapy Intervention for the Treatment of Binge Eating in Bariatric Surgery Patients

Binge eating is a negative indicator of post-surgical weight loss and health outcome in bariatric surgery patients (Hsu, Bentancourt, Sullivan, 1996). Cognitive-behavioral techniques and mindfulness-based practices have been shown to successfully treat binge eating (Agras, Telch, Arnow, Eldredge, & Marnell, 1997; Kristeller & Hallett, 1999). This report describes the development and implementation of a 10-week cognitive-behavioral mindfulness-based group intervention designed to reduce binge eating and address the specific needs of bariatric surgery patients. Posttreatment data showed improvement in binge eating symptoms, depressive symptomatology, and emotion regulation skills and increased motivation to change maladaptive eating behavior.     

Eating Disorders,Impaired Mentalization,and Attachment: Implications for Child and Adolescent Family Treatment

ABSTRACT

This article reviews the attachment and neuroscience model of Mentalization Based Treatment (MBT) (Allen, Fonagy, & Bateman, 2008) and its application for understanding and treating eating disorders (Skarderud & Fonagy, 2012). Mentalization, or mentalizing, refers to the capacity to apprehend one’s own and others’ behavior in terms of underlying mental states (needs, emotions, desires, beliefs, goals, reasons, and thoughts). Evidence from prospective studies suggests that insecure attachment and poor mentalizing difficulties may be risk factors for the development of eating pathology (Jewell et al., 2015; Rothschild-Yakar, Levy-Shiff, Fridman-Balaban, Gur, & Stein, 2010; Rothschild-Yakar & Stein, 2013). Preliminary research on the use of MBT for treating eating disorders, with nonsuicidal self-injury co-morbidity, suggests some promise for this model (Robinson et al., 2015). The theoretical rationale and key interventions of the MBT eating disorder model (MBT-ED) used in a multicenter research and treatment project are discussed (Skarderud & Fonagy, 2012; Robinson et al., 2015). Modifications of MBT-ED’s structure and techniques are proposed for family treatment of adolescent and child patients with eating disorders. Case example illustrates the impact of problems in the family system with mentalizing capacities on family cohesion, the therapeutic process, and the family’s ability to help the child recover.